Choroidal Tuberculosis in Miliary Disease: A Multimodal Imaging Spectrum Across Iatrogenic and Disease-Mediated Immunosuppression

Purpose To describe the multimodal imaging findings of choroidal tuberculosis in two cases of miliary tuberculosis occurring in the setting of distinct forms of immunosuppression.Method Retrospective analysis of four eyes with miliary choroidal tuberculosis.Results Case 1 was a young male with newly diagnosed HIV infection and a CD4 count of 23 cells/μL presenting with bilateral multifocal choroidal lesions at first ophthalmic evaluation. Case 2 was a 41-year-old male with psoriatic arthritis on long-term methotrexate and adalimumab, with prior treated latent tuberculosis, who presented with a unilateral unifocal choroidal granuloma subsequently progressing to bilateral multifocal choroiditis following miliary dissemination. In both cases, ocular involvement was exclusively choroidal with no anterior chamber inflammation, vitritis, retinal vasculitis, capillaritis, or disc leakage in any eye. Indocyanine green angiography (ICGA) demonstrated the greatest lesion burden, identifying hypofluorescent foci not apparent on fundus fluorescein angiography or autofluorescence. Optical coherence tomography revealed a spectrum from subtle stromal lesions with minimal ellipsoid zone changes to large granulomas with subretinal fluid and choriocapillaris compression. Both cases responded to anti-tubercular therapy; adjunctive intravitreal bevacizumab facilitated resolution of subfoveal subretinal fluid in Case 2.Conclusions Findings from these two cases support the possibility of choroidal involvement in miliary tuberculosis despite absent accompanying intraocular inflammation. ICGA may improve lesion detection and characterization of lesion burden in immunocompromised patients with otherwise unexplained choroidal lesions. These observations also support excluding tuberculosis before initiating empiric corticosteroid therapy, given the potential risk of precipitating systemic dissemination.